Progress towards the goal for a paperless NHS by 2020 has been too slow in the acute sector. Shaun O’Hanlon looks at the challenges and solutions for transforming hospital IT.
Health secretary Jeremy Hunt wants the NHS to have a digital revolution by 2020 - with electronic care records for every patient and interoperable digital systems replacing paper records across all care providers.
NHS England chief executive Simon Stevens’ NHS Five Year Forward View also identifies better IT as a key factor in closing the £30bn funding gap facing the health service.
But while primary care organisations have forged ahead with IT, embracing digital patient records and services such as online appointment booking, the picture looks very different in the acute sector.
Here, paper record keeping is still commonplace, and despite many pockets of innovation, in Mr Stevens’ own words: “progress in hospital systems has been slow”.
You cannot compare primary and secondary care IT without considering their differences. One hospital chief information officer once likened comparing the needs of the two to comparing an oil refinery to a corner shop.
Hospitals are gigantic and complex beasts employing hundreds, if not thousands, of people in very diverse roles and offering a dizzying array of specialist services. The size and complexity of the task, then, is a major challenge for designing hospital IT systems.
How do you deliver systems that meet the needs of so many different environments, while also enabling clinicians to share data so that vital information can follow the patient on their journey through different touch points?
And that is just the technical issue. Some would argue that the much harder nut to crack is the human challenge.
Implementing a new IT system requires change management - a massive issue for any hospital. Different specialists will have different views of how “their” patient record should be used.
Historic ways of working, often allied to a particular clinical expertise, can be hard to modify.
Training is another huge issue. Consider e-prescribing - now regarded a vital requirement for any modern hospital because of the clinical safety benefits it offers, alongside cost saving and better information flow.
To deliver this successfully requires in-depth training. But how can a hospital achieve this against an almost ever-changing roster of staff. Most hospitals are facing a high turnover of junior doctors, not to mention the use of agency staff and locums.
And then we come to budgets, the biggest challenge of all. Meeting complex IT needs within tight budgets is a perfect storm, yet that is precisely the challenge for NHS IT.
The challenges for an acute trust's chief information officer
While primary care IT has forged ahead in supporting paperless practice, acute trusts are more advanced in dealing with interfacing and real time systems in areas such as critical care.
The different approaches adopted by the two sectors reflect the very different challenges they face.
For a chief information officer in an acute trust, major issues include:
- Single system or multiple systems Generally speaking, specialist departments such as pathology, radiology and pharmacy need specialist systems and for some clinical users, the systems are linked directly to machine output. Should you try to do all of this within a single system or should you allow some domains to exist within their departments and specialties, and interface them to each other?
- The lack of standard or high performing system interfaces to allow information to flow as patients move between, for example, emergency department, wards and critical care.
- The infrastructure challenge A typical hospital will support thousands of devices of various types. The level of investment required to buy and maintain an enterprise class architecture on such a large scale is significant.
- Reliability and support A hospital is a fast moving 24/7 environment. The more we rely on IT systems, the less we can put up with any outage - so our chosen IT solutions must be robust and reliable.
Adrian Byrne, director of information management and technology for University Hospital Southampton Foundation Trust
Lessons from primary care
It may look like a rather gloomy situation but it is achievable. A good place to start is to consider a lesson from primary care.
What drove primary care to become such an enthusiastic adopter of technology? The answer is quite simple: primary care IT matured because it had explicit and implicit drivers built into data collection used to support both clinical care and remuneration.
Two good examples are the chronic disease management programmes introduced in the 1990s and the quality and outcomes framework from the 2000s. These programmes led to a step increase in the use of computers by frontline staff.
Hospital IT has not yet achieved this clear link between point of care data collection and hitting targets. While there are emerging maturity indices in existence - for example, the Cloud Data Management Interface and the Healthcare Information and Management Systems Society - these are currently of limited benefit because they do not yet measure meaningful use.
Cracking this challenge will be critical to improve the more widespread adoption of digital working in acute care. The introduction of the technology fund - designed to be a catalyst for the use of IT in the NHS - is a good start, but this needs to be supplemented with a clearer mandate on which projects should be supported.
Funded projects should also be required to show meaningful results, as is becoming common in the US.
Interoperability and shared standards are the new watchwords for NHS IT, and there is no doubt they are critical to the successful delivery of IT in the complex acute care environment.
But they also hold the key to the wider integration of healthcare systems that must underpin the future of the NHS. What use is more connected hospital IT if it cannot also connect with the wider health service?
The recent challenges in accident and emergency have shown the true potential value of properly joined up technology in the NHS. Hospitals and GPs are working at full capacity to deal with vulnerable, elderly patients with complex long term conditions, often admitted via A&E for acute episodes of care.
Hospitals need to be able to make informed, timely discharges of these so called “bed blockers” who are often stuck in hospital because of a lack of coordination between primary and secondary care.
To keep the care pipeline flowing freely, hospitals need electronic access to such patients’ health and social care plans in the community. Also, GPs, social care and community staff need hospital discharge data within hours, not days or weeks. The result is patients returning home more quickly to receive appropriate health and social care.
Data sharing also helps reduce the estimated 20 per cent of readmissions that are the result of prescribing errors or confusion around discharge medication.
How do we achieve this nirvana of joined up care? NHS England must bring a firmer approach to not only developing but, crucially, mandating common clinically based standards. It is only with these in place that hospital systems can begin to achieve the step-change needed.
Making it happen
Ultimately, better hospital IT is not just about the technology: it is about a change management process. Introducing a new IT system is a big decision, especially in a costly hospital environment, which can be held back by fear of failure.
Implementation is another obstacle: hospitals are not places where clinicians are typically sitting in one place in front of a screen, so access to machines and mobility needs to be taken into account. Of course, training is a major hurdle too.
The key to success is to anticipate and address all of these challenges - in other words, to deliver whole systems change. A whole systems approach would deliver a workflow to ensure the diverse number of people working in a hospital could each be presented with their view of the information needed to do their job to support properly integrated patient care.
It is certainly an ambitious goal, but one that is absolutely achievable with the support of an experienced IT partner and the buy-in of clinical staff.
Ultimately, systems have to make users’ jobs easier, enable them to make better decisions, reduce errors, improve efficiency and provide better outcomes for patients.